Does investor-ownership of nursing homes compromise the quality of care?

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories ("quality of care," "quality of life," and "other") and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.     

Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality

Objectives

To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality.

Design

Retrospective observational study.

Setting

A National Health Service Trust in London.

Participants

A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013.

Main outcome measures

Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death.

Results

Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43–13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85–7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59–2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26–2.06).

Conclusions

Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality.     

Does investor ownership of nursing homes compromise the quality of care?

OBJECTIVES: Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality. METHODS: We analyzed 1998 data from state inspections of 13,693 nursing facilities.We used a multivariate model and controlled for case mix, facility characteristics, and location. RESULTS: Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes. CONCLUSIONS: Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.     

A longitudinal evaluation of residents’ health outcomes in nursing homes and residential care homes in Taiwan

Purpose  

The role of nursing homes (NHs) and residential care homes (RHs) frequently overlaps in Taiwan, raising concerns about their level of care. This study aimed to investigate residents’ health outcomes in NHs and RHs 1 year after admission.     

Do recommendations for institutional food service result in better food service? A study of compliance in Danish hospitals and nursing homes from 1995 to 2002-2003

BACKGROUND: Since 1995, significant efforts by authorities and researchers have been directed towards addressing the nutritional problems in Danish hospitals and nursing homes. AIM: The purpose of this study was to investigate whether the increased focus on nutritional problems in patients and nursing home residents has resulted in measurable progress. DESIGN: A questionnaire-based study was carried out among foodservice managers in Danish hospitals (n=96) and nursing homes (n=898) in 1995 and 2002/3 (n=90) and (n=682), respectively. The study used compliance with selected issues in the official Danish recommendations for institutional food service as an indicator for progress. The issues included: using nutrient calculated recipes/menus, offering menu choice options, using feedback routines on acceptability of menus, maintaining nutritional steering committees, employing food and nutrition contact persons, employing official recommendations and offering choice between three different menu energy levels. RESULTS: Hospitals had a higher compliance compared to nursing homes. In 1995, this was the case for all questions asked and differences were statistically significant. Also in 2002/3, hospitals had a higher compliance, except in the case of established feedback routines. Differences were statistically significant. The results indicate that nutritional care is higher on the agenda in hospital, than in nursing homes. However, very little progress can be seen in compliance when results are analysed over the 8-year period. The only progress for nursing homes was that more homes had implemented feedback routines on acceptability of food service in 2002/3 than in 1995. The difference was statistically significant. For hospitals, however, no progress was found between 1995 and 2002/3. CONCLUSION: The attempts to improve the nutritional status of hospital patients and nursing home residents seem to have failed. Still, the initiatives taken to improve the situation seem relevant. Especially the nursing homes might benefit from advantage of these experiences.     

What is return to work? An investigation into the quantification of return to work

Purpose

To describe and demonstrate issues with return to work (RTW) outcome metrics in common use among clinical researchers and injury compensation organisations. We also aim to describe a framework on which to capture relevant RTW information including current employment status and data on participation and maintenance.

Methods

Structured telephone interviews discussing participant health and vocational status were conducted following compensable transport-related injury. Participants who were working at the time of injury and took time off work because of their injuries (N?=?414) were asked questions relating to their work participation and maintenance, including length of continuous employment, hours worked and duties performed before and after injury. A series of RTW metrics was developed and applied to survey data. Rates of RTW according to each metric were calculated.

Results

Eighty-four per cent of participants had achieved some employment since their injury, and 74% were working at the time of the survey. In contrast, only 58% of participants were working the same hours as prior to their injury and had been doing so for at least 3?months. These data show that different impressions of rehabilitative success can be obtained depending on the criterion used to define RTW suggesting that reliance on a single RTW index (e.g. ??are you currently working???) will not represent important characteristics of employment.

Conclusion

A multi-layered approach to measuring RTW that includes data on reasons for not working, length of continuous employment, hours and duties performed after injury provides greater insight into the vocational status of injured individuals compared to single metrics or outcomes that fail to capture key detail on motives and participation. This information can assist clinicians to more accurately monitor the progress of rehabilitation following injury and compensation schemes to more effectively monitor their performance.     

Does quality pay for nursing homes?

Using physical restraints, urethral catheterization, pressure ulcers, psychotropic medication use, and contractures as quality indicators, this research examines whether the quality of nursing homes is associated with private-pay census. The primary data source was the 2000, 2001, and 2002 Online Survey Certification And Recording (OSCAR) data, which is nationally representative data containing information for approximately 17,000 nursing homes. The results of this study suggest that physical restraint use and psychotropic medication use have both a correlative and predictive relationship with private-pay census. Catheterization, pressure ulcers, and contractures are less important. The results of this study are important in two ways. First, the cross-sectional results show that the higher quality nursing homes are likely to have a higher private-pay census. Second, the change score analyses show that nursing homes can increase their private-pay census by increasing quality.     

Use of medication technicians in US nursing homes: part of the problem or part of the solution?

OBJECTIVES: To determine the relation between organizational characteristics and medication technician (MT) use and quantify the impact of MTs on increasing the likelihood of using medications, employing the example of antiosteoporosis medications. DESIGN: Cross-sectional study. SETTING: The setting included 6344 Medicare/Medicaid certified nursing homes in 23 states. PARTICIPANTS: Residents older than 65 years of age. MEASUREMENTS: On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. The Minimum Data Set (MDS) provided information regarding use of antiosteoporosis medications and resident factors. Adjusted estimates of MT use on antiosteoporosis medication use were derived using logistic regression with generalized estimating equations. RESULTS: MT use varied by state (6.7% in Alaska vs 85% in Kansas). Homes with greater nursing staffing levels per 100 beds (CNA, RN, LPN) were less likely to use MTs, while larger homes, homes using physician extenders, and contracting pharmacy services were more likely to use MTs. Homes with MTs were more likely to have medication error rates of at least 5% (10.1% vs 7.3%) than homes without MTs. After adjustment for resident and facility factors, residents in MT facilities were not more likely to receive antiosteoporosis treatment relative to those in homes without MTs. CONCLUSION: These data call into question the use of MTs in nursing homes. Use of MTs may lead to more errors, yet not increase use of medications that are labor intensive to administer.     

What factors influence staff training in residential and nursing homes?

Reports on research conducted in eight residential and/or nursing homes belonging to six different charity organizations. The organizations ranged in size from local bodies dealing exclusively with care homes to large nationals involved in various other activities. However, staff training is a core issue to all of them, and activity directed towards it has met with varying degrees of success. Aims to highlight those indicators which will minimize failure of the training schedule and to make homes aware of the wider issues which affect training schemes.     

Why do nursing homes close? An analysis of newspaper articles

Using Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD'IST) software to extract and examine keywords from text, the authors explored the phenomenon of nursing home closure through an analysis of 30 major-market newspapers over a period of 66 months (January 1, 1999 to June 1, 2005). Newspaper articles typically represent a careful analysis of staff impressions via interviews, managerial perspectives, and financial records review. There is a current reliance on the synthesis of information from large regulatory databases such as the Online Survey Certification And Reporting database, the California Office of Statewide Healthcare Planning and Development database, and Area Resource Files. Although such databases permit the construction of studies capable of revealing some reasons for nursing home closure, they are hampered by the confines of the data entered. Using our analysis of newspaper articles, the authors are able to add further to their understanding of nursing home closures.     

Are social comparisons of homes and cars related to psychosocial health?

BACKGROUND: It has been suggested that perceiving oneself to be inferior to those around one is a psychosocial risk factor associated with ill health. The aim of this study was to examine whether negative social comparisons of the worth of two common assets (homes and cars) were related to psychosocial health (i.e. lower self-esteem and mastery, higher anxiety, and depression). METHODS: A postal questionnaire was sent to a random sample of adults in the West of Scotland (sampling from the 1997 electoral roll, response rate was 50%, achieved sample 2838). RESULTS: Having adjusted for socio-demographic variables, rating one's house/flat as worth less than others was associated with lower self-esteem (P < 0.001) and mastery (P < 0.001) and higher depression (P < 0.007) and anxiety (P < 0.012). Rating one's car as worth less than others was not significantly associated with these psychosocial variables. CONCLUSIONS: Our findings lend some support, but only in relation to the home, to the hypothesis that perceiving oneself to be worse off in relation to those around is related to poorer psychosocial health.     

Do consumers respond to publicly reported quality information? Evidence from nursing homes

Public reporting of quality information is designed to address information asymmetry in health care markets. Without public reporting, consumers may have little information to help them differentiate quality among providers, giving providers little incentive to compete on quality. Public reporting enables consumers to choose highly ranked providers. Using a four-year (2000-2003) panel dataset, we examine the relationship between report card scores and patient choice of nursing home after the Centers for Medicare and Medicaid Services began publicly reporting nursing home quality information on post-acute care in 2002. We find that the relationship between reported quality and nursing home choice is positive and statistically significant suggesting that patients were more likely to choose facilities with higher reported post-acute care quality after public reporting was initiated. However, the magnitude of the effect was small. We conclude that there has been minimal consumer response to information in the post-acute care market.     

Cost efficiency of nursing homes: do five-star quality ratings matter?

Nursing homes may respond to the pressure to reduce costs by reducing quality of care, so the two are related. This study examines the determinants of nursing home costs and cost efficiency, and investigates how various measures of nursing home care quality influence both of these. It applies a one-step stochastic frontier approach to a large panel of California nursing homes surveyed between 2009 and 2013. Quality is measured by three different ratings available on the Nursing Home Compare website: rating on quality measures, rating on the health inspection, and rating on staffing levels. Results show that the rating on quality measures, an outcome-based measure of quality, is inversely related to costs but unrelated to mean cost efficiency. In other words, a better rating on quality measures is associated with lower nursing home costs. The health inspection rating is not associated with either costs or mean cost efficiency. The rating for staffing levels, a structural measure of quality, is negatively associated with cost efficiency. These findings reveal that different measures of quality have different relationships with costs and cost efficiency. The findings suggest that better quality outcomes in nursing homes may be achievable with fewer resources and/or improved care procedures, which in turn should reduce nursing home costs.     

Technical efficiency of nursing homes: do five-star quality ratings matter?

This study investigates associations between five-star quality ratings and technical efficiency of nursing homes. The sample consists of a balanced panel of 338 nursing homes in California from 2009 through 2013 and uses two-stage data envelopment (DEA) analysis. The first-stage applies an input oriented variable returns to scale DEA analysis. The second-stage uses a left censored random-effect Tobit regression model. The five-star quality ratings i.e., health inspections, quality measures, staffing available on the Nursing Home Compare website are divided into two categories: outcome and structure form of quality. Results show that quality measures ratings and health inspection ratings, used as outcome form of quality, are not associated with mean technical efficiency. These quality ratings, however, do affect the technical efficiency of a particular nursing home and hence alter the ranking of nursing homes based on efficiency scores. Staffing rating, categorized as a structural form of quality, is negatively associated with mean technical efficiency. These findings show that quality dimensions are associated with technical efficiency in different ways, suggesting that multiple dimensions of quality should be included in the efficiency analysis of nursing homes. They also suggest that patient care can be enhanced through investing more in improving care delivery rather than simply raising the number of staff per resident.